Over recent years debate has built up around the optimal age to start weaning: is it four months or six months, or somewhere in between? Parents are left to bounce back and forth according to opinions of interested groups, so I hope this chapter will help you cut through the ideologies and look at the facts we have.
The age of weaning has varied both historically and between different countries and cultures. The advice today, from the Department of Health in the UK and, indeed, other parts of the world, is based on the World Health Organization’s recommendations: that it is best to exclusively breastfeed your baby for the first six months. The current UK advice1 is to introduce solids when your baby is ‘developmentally ready’, which for most babies is at six months (26 weeks) of age, with room for individual variation.
What is clear is that you should not wean your baby before 17 weeks of age (see here). Equally there is no benefit in waiting beyond six months, as babies are running out of the nutrient stores laid down during the last few months of pregnancy. Six months; individual variation; 17 weeks; and a whole lot of commentary on the subject – it’s easy to see why it feels a bit muddled!
You should not wean babies before 17 weeks of age due to:
The inability to move foods around the mouth, leading to an increased risk of choking
The increased risk of allergy, as the gut is not yet mature enough to process other foods
The baby being likely to take less breast or formula milk, leading to decrease in energy and essential nutrients
The immaturity of the kidneys to cope with the waste products that certain foods create
The increased risk of later obesity
If you are wondering whether your baby may be ready for solids before six months, you can look out for signs to help you decide (see here) and consider the evidence. You can also discuss it with your health visitor if you need.
It is worth noting that although you sometimes hear people refer to a previous weaning age of four months (17 weeks), this isn’t strictly right. The NHS advice back in 1994, when the last big review of weaning was carried out, was to start weaning ‘between four and six months’.
The World Health Organization states that breast milk meets the nutritional needs of babies until six months of age, after which the introduction of other foods is required.2 A Cochrane Review3 and the UK Scientific Advisory Committee on Nutrition (SACN)4 reviewed and agreed with the evidence that exclusively breastfeeding for six months is nutritionally adequate, with no risks to the baby. However, SACN cautioned that there should be individual flexibility in advice given so that babies are weaned when they are ‘developmentally ready’. There is evidence and agreement that by six months babies are running low on essential nutrients, particularly iron and zinc. If you have decided to formula feed your baby then the same advice applies, this is all your baby needs for the first six months.
I encourage mums to try not to wean their babies until they are around six months of age, when they are developmentally ready and no longer satisfied by milk feeds. I often say ‘let’s see how close to six months we can get’, and many get all the way there. It is unusual these days that I see a baby of four months (17 weeks) being given solid food and I just don’t see babies at four months that I feel need to start on solid foods. I would encourage you not to wean at 17 weeks. In fact, the UK government’s ‘Infant Feeding Survey’ shows that fewer and fewer babies are being given solid foods at four months. It’s not unusual to see babies between five and six months happily starting on solids, and there is no evidence to date that this causes harm. However, there is no benefit to delaying weaning beyond six months, when milk feeds are no longer nutritionally adequate.
The signs that your baby is developmentally ready for weaning are accepted to be:
When your baby is able to support his head, neck and upper body in a sitting position – although he may need support from a highchair or similar to stay sitting
When he can reach out, grab food and put it in his mouth
When he is able to control the food in his mouth and swallow it (at some time between four and six months the baby’s tongue-thrust reflex diminishes – prior to this, food is pushed back out of the mouth)
The last UK Infant Feeding Survey (in 2010) stated that some of the parents who had started weaning their baby before six months said they had done so as they had observed that their baby was able to sit with support and hold food.5 However, the equally important question for you to ask for babies less than six months of age is: ‘Is my baby still satisfied with milk feeds?’
If your baby is less than six months old and seems to be developmentally ready but is still satisfied with milk feeds (i.e. he is happy and settled after his usual breast- or formula feed), you can hold off introducing solid foods and see how things are in a week or so. If you are unsure, you could discuss this with your health visitor.
Occasionally GPs or paediatricians ask parents to wean before six months for medical reasons, and if that is the case you will need to start with purées and follow any specific advice you are given.
‘I had planned to wean Monty at six months but the GP advised to start earlier at 23 weeks because Monty had reflux.’
Rosie, mum to Monty, six months
Actually, only a minority of parents now start to wean at four months; three-quarters of parents wean later than this. A common reason given by parents for starting weaning early is that their baby is no longer satisfied with milk feeds. If your baby is less than six months old you can usually increase the amount of milk that you are giving your baby. Breast and formula milk will satisfy your baby more, and contain more nutrients and energy than mashed fruit or vegetables.
Grandparents sometimes advise parents to wean early as they remember the advice they were given when you were a baby. (Back in the early 1980s the guidelines were that in exceptional cases weaning could begin at three months; however, through ongoing research, we now know that this is wrong.) If you find yourself in the situation of receiving well-meaning advice from older relatives, explain that our understanding of nutrition has changed through research, which evolves over time. In the same way that your relatives followed the best advice of that time, you would like to do the same. You may also feel pressure from other parents to wean early. Don’t give into this; feel reassured that you are making your own decision based on your own baby, and don’t change your plans to justify the choices of others.
Q My baby chews on her fingers. Does that mean she needs solid foods?
A No, many babies chew on their fingers or hands, or anything else they get in their mouth. She may do this as a self-soothing method or it may be that she has found her fingers and is gaining enough co-ordination to get her hands in her mouth. It’s not a sign of being ready for weaning.
Q My baby seems extra hungry. Does he need solid foods before six months?
A The types of solid foods usually introduced before six months (vegetable or fruit purée) tend to contain fewer nutrients and less energy than breast or formula milk. Introduction of foods at this age is likely to result in your baby taking less breast or formula milk and therefore getting less energy and fewer nutrients. If your baby seems hungry and he is less than six months old, try increasing milk feeds first, before thinking about introducing solid foods.
Q My baby is longer and heavier than average. Do you think he will need solids before six months?
A Bigger-than-average babies do not automatically need solids earlier than other babies. I regularly saw a breastfed baby who was on the 91st centile for weight and 98th for length, and he was perfectly happy on breast milk, with his mum starting solids during the week he was six months old. The mum and I discussed the evidence for waiting for six months as well as watching for ‘developmental readiness’. It may be worth noting that this baby was breastfed completely on demand, not by routine. He took to solid food very well!
Q My baby is 18 weeks old and he takes 200 ml (7 fl oz) of formula at about 7am, 11.30am, 4pm and 8pm. He takes another 140 ml (5 fl oz) at 11pm. He finishes every bottle and it seems like a lot of milk. My aunt says I should give him solid foods.
A Research has identified that family and friends are an important influence on a mother’s decision to wean her baby. We have learnt a lot about breast- and formula feeding since your parents’ generation were weaning babies, as well as more appropriate times to introduce solid foods, and we now know that it can be better for your baby to wait a bit longer.
An average 18-week-old baby boy weighs 7 kg (15½ lb), and your baby is taking an acceptable amount of milk. He seems satisfied with what he is having at the moment, but I suspect he may soon want a bit more – and you are still able to increase the amount of milk he has at each feed.
By six months, whether you have breast- or formula fed your baby, his supply of nutrients will be getting low. Therefore there is no advantage in waiting longer to start solid foods. Developmentally, by six months babies are ready for solid foods and keen to try.
When you start weaning your baby at six months life becomes easier – your baby is able to put food in his own mouth and is more able to signal when he wants more food or is full up. Also the range of foods you can’t give at six months is very small.
Current UK Department of Health advice is that between six months and one year your baby can’t eat the following:
Honey, due to the risk of it containing botulism spores
Added salt, as babies’ kidneys are not developed enough to deal with salt. As well as your baby not being physiologically ready to cope with added salt, not adding it prevents your baby getting used to the taste of salty foods. The Food Standards Agency recommends infants under one have less than 1 g of salt per day. (As an example, a slice of white bread contains, on average, 0.4 g of salt.)
Added sugar, as this can lead to tooth decay. For babies under one year the advice is no added sugar. After this age, the current UK standard is for no more than 10 per cent of total dietary energy per day from added sugars (such as table sugar or honey, or sugar added to foods and drinks) to prevent tooth decay. This should not be confused with a recommendation to include this much added sugar in the diet. However, this recommendation has recently been challenged by the World Health Organization, which considers 5 per cent more prudent, due to the mounting concerns about the role of sugar in the current obesity epidemic. As your child grows, sugar becomes harder to avoid; see here for ways to manage this.
Whole nuts, due to risk of choking – see here for nut restrictions
Liver pâté, as it contains a lot of vitamin A, which may be harmful to babies
Shellfish should not be given, due to the risk of food poisoning
Certain fish such as shark, marlin or swordfish should not be given due to the levels of mercury and other contaminants found in these fish
Some foods have restrictions at six months:
Fish: Other than the restrictions given above, fish is fine, but remember that girls and women of child-bearing age should only have oily fish (salmon, herring, mackerel) up to twice a week; boys can have it up to four times a week (for more on this, see here).
Nuts: While whole nuts should not be given to children under five, due to the risk of choking. If there is no history of allergy in your family your baby can have thinly spread nut butters or ground nuts from six months.
Cow’s milk cannot be given as a drink before one year but from six months can be used in cooking and added to breakfast cereals. Milk and dairy products should be full-fat and pasteurised.
Eggs can be given from six months but you need to cook the white and yolk so they are solid until your baby is one year old.
By six months most babies are able to do ALL of the actions described here that suggest ‘developmental readiness’. If your baby cannot, you should discuss this with your health visitor or GP.
If your baby has difficulty in co-ordination or a delay in milestones, you should seek advice from your baby’s health team prior to six months so that you can decide how to start weaning when the time comes.
Daisy’s mum attended clinic to discuss weaning. We could see that her weight gain had been along the 9th centile line (in the Personal Child Held Record – the Red Book). Daisy had been exclusively breastfed, and was now 21 weeks old. Her mum felt that Daisy appeared to meet the developmental milestones associated with weaning and wondered whether she should start to give Daisy solid food. We looked at Daisy’s weight gain, which remained consistent; she always woke once in the night for a short breastfeed and usually fed three to four hourly in the daytime. Daisy seemed to be just as settled as she had always been, but her mum was wondering whether giving Daisy some food would help her sleep all night.
I explained to mum that as Daisy had always woken at night it was unlikely that this was due to increased hunger. I asked mum if we could try some ideas to help Daisy sleep through rather than introduce solid food, which was unlikely to be the answer. Daisy’s mum agreed to try, and we discussed some ideas to help Daisy sleep through, such as putting Daisy to bed when she was awake instead of breastfeeding her to sleep. This stopped Daisy associating sleep with a feed. At the same time her mum also shortened the length of the nighttime feed. Within 10 days Daisy was sleeping all night and now consistently had five feeds in the daytime. Daisy became increasingly interested and excited when her mum and family sat down to eat so Mum decided to start weaning at 24 weeks with puréed foods, which she built up to soft lumps and finger foods by 28 weeks.
Sometimes parents are advised by a health professional to wean their baby before he reaches six months of age. This may be because the baby was premature, or has had persistent gastro-oesophageal reflux disease or another health condition. If you feel certain that your baby is ready for solid foods before six months due to a non-health-related reason, you should discuss this with your GP or health visitor. You need to be careful with the types and textures of foods that you give, as there are more restrictions than for babies over six months.
Before six months it is recommended that babies have puréed foods to prevent choking. If you are only a week or two off six months you may feel that your baby can start with mashed foods or, in some cases, soft pieces of foods, but that is a very individual decision and not one I could advise through the distance of a book. You must make that decision with your baby’s safety as paramount – not because you wish to pursue a certain method.
There are certain foods that you are often advised to avoid when weaning early to help prevent allergies or illness. The NHS advises that these are: eggs, wheat, gluten, cow’s milk, fish and shellfish, nuts and peanuts, soft and unpasteurised cheeses, seeds, honey, liver and pâté.
The foods at higher risk of causing allergy are: eggs, wheat, gluten, cow’s milk, fish and shellfish, nuts, peanuts and seeds. Debate exists over whether the avoidance of these foods before six months helps allergy prevention. Some advice suggests that in babies with no allergy risk (that is, the parents have not suffered from any type of allergy themselves and there is no family history of any type of allergy), avoidance of these foods will not alter their allergy risk. This advice is being reviewed by the UK Scientific Advisory Committee on Nutrition. The results of that review are expected in 2015. Further advice on allergy is given in Chapter 8.
Despite the existence of some prescriptive advice, other than the current allergy and food safety advice (here) there is little evidence for starting weaning with any particular type of food. At four months a gentle start is appropriate, and vegetables, fruit or baby rice are traditionally used. However, there is no reason that you must start weaning with baby rice – vegetables and fruit are appropriate for first tastes. Interestingly Canada has recently started to recommend meat and eggs as first foods from six months. This is because these foods supply iron and zinc – nutrients that, by six months, babies are starting to run low on.
A baby is considered to be premature if born at less than 37 weeks’ gestation. Therefore, the range of prematurity and any associated problems is large. The earlier a baby is born, the greater the risk of associated problems.
Bliss, a UK charity for babies born early or sick, has produced weaning guidance in association with health visitors, specialist nurses and dietitians. As a general guide, they advise that premature babies are weaned between five and eight months of age. This age is calculated from their actual birth, not the age they were due to be born. Most babies will need to have reached three months corrected age (the age of your baby from the due date) to have enough head control to be able to wean safely.
You should assess your baby’s readiness to wean alongside your health visitor – or your health care team if your baby is still under the care of a neonatal or developmental team.
Without any other health or development concerns your baby would be weaned in exactly the same way as any other baby. However, for some premature babies there are additional considerations. Your baby may be smaller than others and eating smaller amounts.
If you are worried about growth, you can make meals more energy dense. Vegetables may contain many vitamins but are usually low in energy. You can add starchy foods (such as potatoes or sweet potatoes) to vegetables to increase the amount of energy your baby gets. You can also add cheese, butter or oils to dishes. Mix dishes or cereals with your baby’s usual milk to be fed from a spoon. Do not add cereals to your baby’s bottle.
You can take your baby to be weighed to see if weaning is having any impact on your baby’s growth. Plan with your health visitor how frequently you should have your baby weighed, as frequent weighing can make you feel anxious. If weight gain is a problem you may need to be referred to a dietitian.
Premature babies are not at higher risk of food allergies; however, gastro-oesophageal reflux disease is more common. If your baby has suffered gastro-oesophageal reflux disease you may be advised when to start weaning as solid food can help prevent regurgitation.
If your baby is tube fed, has swallowing difficulties or co-ordination problems, you will be supported through weaning by your health care team.
Many premature babies, particularly earlier ones, are given prescribed vitamin drops, although this may depend on the type of milk feeds they receive. If your baby has not needed prescribed vitamins then the advice is the same as for all babies, and is discussed in Chapter 5 (here).
Breast milk or formula is all a baby needs for the first six months. If you are considering weaning your baby before six months it should be because your baby needs solid foods. If unsure, talk it through with your health visitor.
Your baby’s size, and whether he sleeps all night or not, are not reliable indicators of needing to wean.
If your baby is not interested in solid foods, stop and think about it again in a couple of weeks.
You have a responsibility to feed your baby healthy foods in a way that is responsive to his needs.